Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Shake and call the client's name.

Press firmly on the center of the sternum.

Use aromatic spirits of peppermint.

Run a pointed object up the sale of foot.

Answer and Explanation

The Correct Answer is B

A.   Shaking the client and calling their name is generally used to assess responsiveness in clients who are not deeply unconscious but may be drowsy or semi-conscious. However, in clients with a marked reduction in LOC, this approach might not be effective because it does not provide sufficient stimulation to elicit a response from someone with significantly diminished consciousness.
B.   Applying firm pressure to the center of the sternum (sternal rub) is an effective method for assessing a client's response to painful stimuli, especially when there is a marked reduction in LOC. This technique involves using the knuckles to rub or press firmly on the sternum, which provides a strong and potentially painful stimulus to evaluate the client's responsiveness.
C.   Aromatic spirits of peppermint are used to stimulate a client's sense of smell but are not effective for assessing response to painful stimuli. This method is more suitable for clients who are semi-conscious and may respond to sensory stimulation but does not provide the level of stimulation needed for assessing deep unconsciousness.
D.   Running a pointed object up the sole of the foot is a method used to test the plantar reflex (Babinski reflex) and is not typically used to assess a response to painful stimuli. This method might be useful in neurological assessments but does not provide sufficient stimulation to assess responsiveness in a client with a marked reduction in LOC.

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Correct Answer is A

Explanation

A. A mental status exam is a comprehensive assessment tool used to evaluate various aspects of cognitive function, including orientation, memory, attention, language, and higher cognitive functions. Given that the client is confused, a mental status exam is highly relevant to understand the scope of the confusion, identify possible underlying issues, and provide a baseline for further evaluation and treatment.
B. Eliciting a pain response is typically used to assess responsiveness in patients who are not fully conscious or are unresponsive. Since the client is described as alert and ambulatory, attempting to elicit a pain response is not the most appropriate next step. This action is more suited for assessing levels of consciousness in patients who are less responsive or in coma-like states.
C. The Babinski reflex is a neurological test where the sole of the foot is stroked to assess the presence of an abnormal reflex response. In adults, the presence of the Babinski reflex may indicate neurological damage. This test is more specialized and less relevant for a general assessment of confusion.
D. Assessing pupillary accommodation involves checking how well the pupils adjust to changes in light and focus. While this is an important part of a neurological assessment, it is not the most direct approach to addressing confusion. Pupillary responses are generally assessed alongside other neurological evaluations but do not specifically address the cognitive or confusion aspects of the mental status.

A. Wrist - able to bend wrist back toward forearm B. Elbow - only able to straighten joint 30 degrees

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

Wrist: Able to bend wrist back toward forearm

Flexion: When the wrist bends back toward the forearm, it is an example of flexion. Flexion decreases the angle between the wrist and the forearm.

Elbow: Only able to straighten joint 30 degrees

Extension: The ability to straighten the elbow is indicative of extension. In this case, the client is only able to straighten the elbow to 30 degrees, which reflects limited extension.

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Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

Correct Answer is A

Explanation

Patient Data Exhibits

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

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